(Emphasis in original)
115 Mr Tilton was cross-examined at length about, among other things, his inspection of the vessel, the defects or "non-conformances" he observed on it, the associated risk of fire and the need to remove that risk. Before setting out the more salient extracts from that cross-examination, it is convenient, first, to explain the origins of the expression "non-conformances". That expression comes from section 6 of Mr Ritchie's first report as follows:
6 Identified non-conformances
Mr Tilton identified various non-conformances with the LV and ELV systems which in my opinion presented electrical risk, were not electrically safe and were serious defects.
I address each one in turn.
6.1 Defect 1 - No LV terminal covers on air-conditioners
Noted in the Tilton Interview Q73, 74, 75& 76 and Photo 2016-05-27 11:22;
Expert Opinion - The exposed live LV terminals at the air conditioners pose a significant risk of electric shock and/or fire.
The Wiring Rules (AS/NZS 3000:2007) refers to this as basic protection (protection against direct contact) and in clause 1.5.4.1 states "Protection shall be provided against the dangers that may arise from contact with parts of the electrical installation that are live in normal service". The Wiring Rules continue in clause 1.5.4.2 to describe methods of basic protection as being one or a combination of:
- Insulation;
- Barriers or enclosures;
- Obstacles;
- Placing out of reach.
To alleviate the risk of electric shock or fire the exposed live terminals could be enclosed in an insulating terminal box.
That work itself poses the same significant risk of electric shock however the LV electrical energy could be disconnected to safely repair the air conditioner terminal covers to a safe and compliant condition.
If Mr Tilton did not intend to repair it, he needed to disconnect the supply source to make it electrically safe for himself and others on board.
6.2 Defect 2 - Broken hinge on LV switchboard door exposing live terminals due to the lack of an escutcheon panel.
Noted in photo 2016-05-27 14:45 and photo 2016-06-02 11:23
Expert Opinion - The exposed live LV terminals in the engine room LV switchboard pose a significant risk of electric shock and/or fire.
The Wiring Rules (AS/NZS 3000:2007) refers to this as basic protection (protection against direct contact) and in clause 1.5.4.1 states "Protection shall be provided against the dangers that may arise from contact with parts of the electrical installation that are live in normal service". The Wiring Rules continue in clause 1.5.4.2 to describe methods of basic protection as being one or a combination of:
- Insulation;
- Barriers or enclosures;
- Obstacles;
- Placing out of reach.
To alleviate the risk of electric shock or fire the switchboard housing the exposed live terminals could be replaced or repaired with an escutcheon panel and correctly functioning door hinge.
That work itself poses the same significant risk of electric shock however the LV electrical energy could be disconnected to safely repair the engine room LV switchboard to a safe and compliant condition.
lf Mr Tilton did not intend to repair it, he needed to disconnect the supply source to make it electrically safe for himself and others on board.
6.3 Defect 3 - Wiring not terminated in a Junction Box
Noted in the Statement of Claim 16(g) (iv), the Defence 16g (iv), Tilton Notes "A/C", Tilton interview Q47, Photo 2016-05-27 15:46;
Expert Opinion - Any exposed live LV terminals or single insulated wiring associated with terminations not enclosed in a junction box pose a significant risk of electric shock and/or fire.
The Wiring Rules (AS/NZS 3000:2007) refers to this as basic protection (protection against direct contact) and in clause 1.5.4.1 states "Protection shall be provided against the dangers that may arise from contact with parts of the electrical installation that are live in normal service". The Wiring Rules continue in clause 1.5.4.2 to describe methods of basic protection as being one or a combination of:
- Insulation;
- Barriers or enclosures;
- Obstacles;
- Placing out of reach.
To alleviate the risk of electric shock or fire any terminations with exposed live terminals or single insulated wiring could be enclosed in an insulating junction box.
That work itself poses the same significant risk of electric shock however the LV electrical energy could be disconnected to safely repair any exposed live LV terminals or single insulated wiring to a safe and compliant condition.
If Mr Tilton did not intend to repair it, he needed to disconnect the supply source to make it electrically safe for himself and others on board.
6.4 Defect 4 - Engine lights incorrectly earthed
Noted in the Statement of Claim 16g (v), the Defence 16g (v), Tilton Notes "To Do List", Tilton interview Q47, Photo 2016-05-27 14:22;
Expert Opinion - Earthing (or equipotential bonding on an electrically separated system) is a primary means of ensuring circuit protective devices provide automatic disconnection of supply in under 400mS in the event of a fault, providing protection to the installation from fire and some protection against inadvertent shock. The engine room lights were identified as being unearthed and many were damaged.
The Wiring Rules (AS/NZS 3000:2007) refers to this as fault protection (protection against indirect contact) and in clause 1.5.5.1 states "Protection shall be provided against the dangers that may arise from contact with exposed conductive parts that may become live under fault conditions". The Wiring Rules continue in clause 1.5.5.2 to describe methods of fault protection as being one or a combination of:
- Automatic disconnection of supply;
- The use of class II equipment (double insulated equipment);
- Electrical separation;
- Limiting the fault current that can pass through a body to a value lower than the shock current.
To alleviate the risk of electric shock or fire posed by incorrectly earthed or bonded engine room light fittings, the correct earth or bonding conductor could be fitted to each light fitting and the damaged light fittings repaired or replaced.
That work itself poses the same significant risk of electric shock however the LV electrical energy could be disconnected to safely repair any damaged and/or incorrectly earthed or bonded engine room light fittings.
If Mr Tilton did not intend to repair it, he needed to disconnect the supply source to make it electrically safe for himself and others on board.
6.5 Defect 5 - Switchboard unearthed
Noted in the Statement of Claim 16g (vii) and the Defence 16g (vii);
Expert Opinion - Earthing (or equipotential bonding on an electrically separated system) is a primary means of ensuring circuit protective devices provide automatic disconnection of supply in under 400mS in the event of a fault, providing protection to the installation from fire and some protection against inadvertent shock. The LV switchboard was identified as being unearthed.
The Wiring Rules (AS/NZS 3000:2007) refers to this as fault protection (protection against indirect contact) and in clause 1.5.5.1 states "Protection shall be provided against the dangers that may arise from contact with exposed conductive parts that may become live under fault conditions". The Wiring Rules continue in clause 1.5.5.2 to describe methods of fault protection as being one or a combination of:
- Automatic disconnection of supply;
- The use of class II equipment (double insulated equipment);
- Electrical separation;
- Limiting the fault current that can pass through a body to a value lower than the shock current.
To alleviate the risk of electric shock or fire posed by an incorrectly earthed or bonded LV switchboard, the correct earth or bonding conductor could be fitted to the LV switchboard.
That work itself poses the same significant risk of electric shock however the LV electrical energy could be disconnected to safely repair any necessary LV switchboard earth or bonding conductor.
If Mr Tilton did not intend to repair it, he needed to disconnect the supply source to make it electrically safe for himself and others on board.
6.6 Defect 6 - Main earth too small
Noted in the Statement of Claim 16g (vi) and Tilton interview Q47;
Expert Opinion - Earthing (or equipotential bonding on an electrically separated system) is a primary means of ensuring circuit protective devices provide automatic disconnection of supply in under 400mS in the event of a fault, providing protection to the installation from fire and some protection against inadvertent shock. The main earth was identified as being undersized.
The Wiring Rules (AS/NZS 3000:2007) refers to this as fault protection (protection against indirect contact) and in clause 1.5.5.1 states "Protection shall be provided against the dangers that may arise from contact with exposed conductive parts that may become live under fault conditions". The Wiring Rules continue in clause 1.5.5.2 to describe methods of fault protection as being one or a combination of:
- Automatic disconnection of supply;
- The use of class II equipment (double insulated equipment);
- Electrical separation;
- Limiting the fault current that can pass through a body to a value lower than the shock current.
To alleviate the risk of electric shock or fire posed by an undersized main earth, the correct earth conductor could be fitted if it was required.
That work itself poses the same significant risk of electric shock however the LV electrical energy could be disconnected to safely repair the cable if necessary.
If Mr Tilton did not intend to repair it, he needed to disconnect the supply source to make it electrically safe for himself and others on board.
6.7 Defect 7 - Exposed ELV live terminals
Noted in the Photo 2016-05-27 15:56;
Expert Opinion - Exposed ELV terminals pose a risk of short circuit and fire due to potentially high current flow causing excessive heat dissipation.
The NSCV (National Standard for Commercial Vessels) C.5.5b clause 2.15.3 states "Cable connections and terminations shall be at fixed, enclosed terminals".
To alleviate the risk of short circuit and fire posed by exposed ELV terminations, the exposed live terminals could be enclosed in an insulating terminal block or fuse box.
That work itself poses the same significant risk of fire however the ELV electrical energy could be disconnected to safely repair the exposed ELV terminals to a safe and compliant condition.
If Mr Tilton did not intend to repair it, he needed to disconnect the supply source to make it safe for himself and others on board.
6.8 Defect 8 - GPO circuits not mechanically protected and insulation non-compliant
Noted in the Statement of Claim 16g (viii), the Defence 16(g) (viii)and Tilton interview Q54;
Expert Opinion - Lack of double insulation and lack of mechanical protection poses a risk of previous or new damage allowing a leakage current to result in electric shock.
The Wiring Rules (AS/NZS 3000:2007) states in clause 3.10.1.1 "Insulated, unsheathed cables shall be enclosed in a wiring enclosure throughout their entire length".
To alleviate the risk of electric shock posed by single insulated cables and lack of mechanical protection, the cabling could be enclosed in a conduit or duct or replaced with double insulated cable with added mechanical protection where required.
That work itself poses the same significant risk of electric shock however the LV electrical energy could be disconnected to safely repair any single insulated or mechanically unprotected circuit wiring.
lf Mr Tilton did not intend to repair it, he needed to disconnect the supply source to make it electrically safe for himself and others on board.
6.9 Defect 9 - Non-compliance with AS/NZS 3000:2007
Noted in the Statement of Claim 16g (ix), the Defence 16g (ix), Pasma Evidence 16(a), Tilton Evidence 13 (c) and Tilton interview Q77;
Expert Opinion - Lack of compliance with standards may harbour initially unknown hazards and risks.
Such non-compliances could be repaired to bring the vessel to a compliant state.
That work itself poses hazards and risks however the electrical energy from both LV and ELV sources could be disconnected to safely repair any identified non-compliance.
If Mr Tilton did not intend to repair it, he needed to disconnect the supply source to make it electrically safe for himself and others on board.
6.10 Defect 10 - Non-compliant with NSCV
Noted in the Statement of Claim 16(g) (x), the Defence 16(g) (x), Pasma Evidence 16(c), and Tilton interview Q91;
Expert Opinion - Lack of compliance with standards may harbour initially unknown hazards and risks.
Such non-compliances could be repaired to bring the vessel to a compliant state.
That work itself poses hazards and risks however the electrical energy from both LV and ELV sources could be disconnected to safely repair any identified non-compliance.
If Mr Tilton did not intend to repair it, he needed to disconnect the supply source to make it electrically safe for himself and others on board.
6.11 Defect 11 - Significant faults
Noted in the Defence 8a;
Expert Opinion - Significant faults may harbour initially unknown hazards and risks.
Such significant faults could be repaired to bring the vessel to a safe and compliant state.
That work itself poses hazards and risks however the electrical energy from both LV and ELV sources could be disconnected to safely repair any identified non-compliance.
If Mr Tilton did not intend to repair it, he needed to disconnect the supply source to make it electrically safe for himself and others on board.
6.12 Defect 12 - Electrical systems were "poor" and/or needed "lots of work"
Noted in the Statement of Claim 16g (ii), the Defence 16g (ii), Pasma Evidence 16(d),Tilton Evidence 13a and Tilton interview Q46;
Expert Opinion - Poor electrical systems in need of "lots of work" may harbour initially unknown hazards and risks.
Such poor electrical systems could be repaired to bring the vessel to a safe and compliant state.
That work itself poses hazards and risks however the electrical energy from both LV and ELV sources could be disconnected to safely repair any identified non-compliance.
If Mr Tilton did not intend to repair it, he needed to disconnect the supply source to make it electrically safe for himself and others on board.
6.13 Defect 13 - Non-compliant colour code of wiring
Noted in the Statement of Claim 16g (iii), the Defence 16g (iii) and in the Tilton interview Q47;
Expert Opinion - Nonstandard colour coding of wiring is a hazard that has the risk of inadvertent confusion.
Such non-compliant colour coding could he dealt with via clear notification and signage to remove confusion.
That work could be safely undertaken whilst the electrical energy from both LV and ELV sources were disconnected for other work being undertaken.
6.14 Defect 14 - Nonfunctional or non-compliant fire system
Noted in the Statement of Claim 16g (xi), Pasma Evidence 16(f) and Tilton Evidence 18;
Expert Opinion - A nonfunctional or non-compliant fire system is a hazard that has a risk of undetected/unextinguished fire causing damage.
The lack of a functional fire system could have been taken into account when carrying out a risk assessment.
6.15 Defect 15 - No electrical drawings
Noted in Pasma Evidence 17 and 18;
Expert Opinion - Lack of electrical drawings is a hazard that has the risk of inadvertent confusion.
Such confusion could lead to error; however, it could can be dealt with by drafting the schematic drawings to remove confusion.
The lack of electrical drawings should be taken into account when carrying out a risk assessment.
6.16 Defect 16 - Unsuitable cable supports
Noted in Tilton Evidence 20c, Tilton interview Q47 and photo 2016-05-27 14:39;
Expert Opinion - Unsuitable cable supports is a hazard due to ambient temperatures that needs to be considered in the scope of works.
6.17 Defect 17 - Unprofessional workmanship evident
Noted in Tilton Evidence 20(f);
Expert Opinion - Unprofessional workmanship may harbour initially unknown hazards and risks.
…
When faced with the electrical risks and hazards set out above, in my opinion a reasonable electrician would have conducted a risk assessment and concluded the appropriate way to make the vessel electrically safe was to isolate power from the LV and the ELV sources of supply.
(Typography and errors in original)
116 Returning, then, to Mr Tilton's cross-examination, the following are the salient extracts from it concerning his inspections of the electrical system on the vessel, the defects or "non-conformances" he observed and their associated risk of fire:
[Inspection]
Now, on 26 May, did you inspect the vessel in the company of Mr Pasma, or did you inspect it on your own?---I believe Mr Pasma was there with me.
And you wandered around the vessel together, is that how I take your evidence?---Yes. Yes.
On that occasion, it was an entirely visual inspection, is that correct?---Yes.
You didn't perform any what might be described as invasive inspection? You didn't remove any panels to look at wiring or anything like that, is that correct?---That's correct.
You didn't test any circuits at that time, is that correct?---Don't think so.
Did you go into the engine room, do you recall?---I would have, yes.
But I take it that you didn't test any of the appliances in the engine room, the electrical appliances, on that occasion, is that correct?---Don't think so.
,..
On this inspection on 27 May, this was again a visual inspection, that's so, isn't it?---Yes.
Again, on this occasion, you didn't undertake any invasive inspection, you didn't remove panels to access wiring or anything like that, correct?---That's correct.
You didn't test any circuits or any of the appliances on this occasion, is that correct?---Excessive polarity on the GPOs in the forecabin area.
But for instance, you didn't carry out any tests on this occasion on the AC switchboard in the vessel, that's correct, isn't it?---That's correct.
Or any of the RCD devices that were in that switchboard, for example, correct?---Yes, I believe so.
And you also didn't carry out any tests on the DC switchboard either on this occasion, I take it?---Yes, I believe so.
When you say you believe so, you agree that you didn't carry out inspections, is that correct?---Yes, I would agree.
[Non-compliances and associated risks - cables not terminating at junction boxes]
Now, one of those non-compliances that you observed was that there were some cables that didn't terminate at junction boxes as they should have; is that correct?---That's correct.
And as a result those cables were exposed at the terminal connections; is that so?---Yes.
…
And what you observed was that there was no terminal cover for the AC power on that air conditioning unit, is that correct?---That's correct.
…
And in its current state, if there was a risk that someone may be electrocuted if they touch that terminal cover, and it was live, that's correct, isn't it?---That's correct.
And also, whilst it was in that condition, there was a risk of the potential of fire, in the event of a short circuit through that connection. That's correct, isn't it?---Possibly.
And they're the risks that one was seeking to avoid by placing it in an insulating terminal box, in accordance with the usual practices as you've just suggested. That's correct, isn't it?---Yes.
And until that was done, that terminal cover in that condition posed a risk or electrical hazard. That's correct, isn't it?---Possibly.
Well, so long as - I withdraw that. At the time you inspected it, it posed - in its current condition, it posed a risk or hazard to somebody either working in that vicinity, or the possibility of fire that I've just put to you. That's correct, isn't it?---If it was on, yes. Maybe.
If the wire was energised, then there was that risk. That's correct, isn't it?---Possible, yes.
And that's a hazard - electrical hazard - which you would seek to eliminate, consistent with good practice. That's correct, isn't it?---That's correct.
And the way to do it in the long term is to use an insulating box, correct?---Correct.
…
And again, where wiring was not terminated in a junction box, such as depicted here, then that meant that there was an exposed live wire where the circuit was energised. That's correct?---Yes.
And that posed the same, or similar risks to those that we've just been discussing in relation to the previous photo, namely, the possibility of electric shock or injury to a person, and the possibility of fire. That's correct, isn't it?---A fire can happen in any short circuit situation - - -
Yes?--- - - - regardless of whether it's in a box or not.
But if it's not in a box, and there is a fire and a short circuit, then it's more likely to escape into other parts of the engine - other parts of the vessel. That's correct, isn't it?---Possible.
And one of the reasons you have an insulating junction box is to prevent a spark that may arise in a short circuit from escaping the circuit, beyond the circuit and into adjoining parts of the ship. That's correct, isn't it?---Well, it's mainly to prevent somebody from touching it.
But it does both, does it not, Mr Tilton?---Yes, I suppose.
And again, until this wire was enclosed in an insulating junction box, it would continue to present the electrical hazard or risk that we've just discussed, whilst ever it was energised. That's correct, isn't it?---Yes.
And again, this isn't a - I withdraw that. Prior to 8 June, you didn't carry out any work on the vessel which involved identifying wires that were in this condition and then enclosing them in an insulating junction box; that's correct, isn't it?---That's correct.
That's something that you were planning to do later or that you had deferred until later; correct?---That's correct.
[Non-compliances and associated risks - broken hinge on switchboard]
Now, the - one of the things that you observed was that the hinge on the AC or the LV switchboard door was broken; that's correct, isn't it?---That's correct.
And, as a result, the panel door - the external door wasn't able to close securely; that's correct, isn't it?---Well, if three points is not secure enough, then yes.
Yes. Well, in that condition, it wouldn't have satisfied the relevant applicable standard to which the vessel was aspiring; that's so, isn't it?---That's correct.
And that was amongst the work that you would be carrying out onboard the vessel; namely, the repair of that door or that hinge; that's correct, isn't it?---That's correct.
And when that was done, then it would be able to be secured and the door would then be - well, would then be certainly more - provide more sealing and be more fireproof than in its current condition as depicted in the photograph; that's correct, isn't it?---That's correct.
…
While the switchboard door was in the condition that's depicted in the photograph, there was - and didn't provide full sealing and fireproofing, then there was an electrical hazard, or some risk, that's correct, isn't it?---For what kind of risk? Electrical shock?
Or electrical - or electrical - or a risk of - in the event of a short circuit in a fire, when the switchboard - it escaping the switchboard?---It's possible, yes.
Well, that's the reason why it should be sealed at all four points and surely, that's correct, isn't it?---Correct.
It's to render it fireproof, or as fireproofed as one can, that's correct, isn't it?---Well, it needs to be closed, as well.
Yes?---It needs to be locked up so that - because it's a switchboard.
Yes?---It has got power in it.
[Non-compliances and associated risks - engine room lighting]
So the ER - the reference to ER lighting is to lighting in the engine room, is that correct?---That's correct.
And the - and - and as you have just said, the lighting needed - needed to be replaced. Do you recall why it needed to be replaced?---They didn't have any cover. They didn't have any glass covers over them, the didn't have lamps. One of them had a - the body was, you know, melted a little bit. They weren't working.
And in all - in all of those - all of those conditions were, I take it, noncompliant with the standard AS/NZS 3000 that you were seeking to bring the vessel up to, correct?---Correct.
And all of that work needed to be done at some stage as part of the work that your company, Pasma Electrical, had been contracted to do, correct?---Yes.
…
Something else that you observed in relation to the engine room lights were that they didn't have earthing. Do you recall that?---That's correct.
And, in relation to that observation, that would include the light that you have just referred to there. Is that so?---It's possible.
Well, is it some of the lights didn't have earthing in the engine room, or all of the lights in the engine room didn't have earthing? Do you recall?---I don't remember.
But they should have had earthing. Is that so?---If it was AC-powered, yes. If it was DC-powered, not necessarily.
To the extent to which you observed that they didn't have earthing, the reason you did so was because they required earthing and that would need to be corrected. That's so, isn't it?---Yes, I said they didn't have any earthing. But if it - if it was DC, then I would - it doesn't need any earthing.
…
Now, the requirement for the light to be earthed is because earthing is a means of ensuring that circuit protective devices on the circuit provide an automatic disconnection in the event of a fault or an imbalance. That's correct, isn't it?---That's correct.
The light is earthed so that the circuit protection devices can operate, and in that way, either eliminate or minimise any injury that might be caused by the short circuit to somebody. That's correct?---Yes, or - yes.
And also to protect against the short circuit producing a fire. That's correct, isn't it?---Correct.
So in the condition that you observed them on board the vessel on 27 May or thereafter, these AC engine room lights were in a condition that posed or presented an electrical hazard or a risk of the type that I have just asked you about. That's correct, isn't it?---If the lights were AC, yes.
[Removing hazard by de-energising the vessel]
And one way of - now, the electricity going into that switchboard is the electricity that is coming from the shoreline into the vessel, at the rear of the vessel that you gave some evidence about earlier. That's correct, isn't it?---That's correct.
So in order to - one way - I withdraw that. One way of addressing or eliminating that electrical hazard or risk that I have just referred to would be de-energising the vessel, that is so, isn't it?---Yes, you can do that.
And if you did that, that would remove any risk associated with the condition of which that switchboard was in at the time it was taken - you took that photograph. That's correct, isn't it?---That's correct.
And it - it wouldn't be possible to address that condition by, for example, isolating any component, or isolating any circuitry, in the switchboard that was up on the helm. That's so, isn't it?---That's correct.
The only way of really dealing with that, if the - until it's repaired, is by addressing the source of electricity into the vessel, correct?---That's correct.
…
What I'm suggesting to you is - do you agree that that was the appropriate course that you should have done?---No. At the time, I didn't think it was necessary.
But what I'm suggesting to you is that now you agree that that's what we should have done?---In hindsight, maybe.
(Headings added, errors in original).
117 Finally in respect of Mr Tilton's evidence pertinent to this inquiry, it is necessary to mention the Daily Job/Service Cards (the Job Cards) that he prepared while he was working on the Miss Angel . They show that he either inspected or worked on the vessel on 27, 30 and 31 May 2016 and on 2, 3, 7 and 8 June 2016. They also show that, on 27 May 2016, he undertook an induction before inspecting the Miss Angel with an electrician referred to as "Lachlan" who noted the inspection as "assess requirements for survey". On 30 and 31 May 2016, they show that he inspected the bilge system wiring on the vessel and carried out repairs on it, including obtaining new parts, installing them and testing the bilge system. Further, they show that he attended a "Production Meeting" and inspected the vessel's battery charger and inverter on 3 June 2016. Finally, they show that he was working on the batteries in the engine room on the vessel on 7 and 8 June 2016.
118 Lastly with respect to this inquiry, it is necessary to mention the second part of the Joint Experts' Report which was devoted to the question of eliminating the risk of fire on the Miss Angel. Before doing so, three things should be noted. First, some of this evidence appears to presume an affirmative answer to the next aspect of this inquiry, namely whether Mr Tilton had a duty to take action to prevent injury or harm being caused to the Miss Angel. Since that is essentially a legal issue to be determined by this Court, that evidence has to be treated accordingly. Secondly, some of this evidence is directed to the proportionate liability issues (Issue 6) and, in particular, to BSE's role as a concurrent wrongdoer in, among other things, connecting the 240 volt AC shore power to the vessel. Thirdly, some parts of the Joint Experts' Report have been excluded below because they are affected by the ruling made later in these reasons concerning the risk assessment issue (see at [203]). With those qualifications, the pertinent parts of the Joint Experts' Report that relate to this inquiry were as follows:
B(1) - Should a licenced electrician disconnect (or ensure that someone else
disconnects) the 240 volt shore power from the Vessel?
Areas of agreement: Yes.
The Experts noted that the action of disconnecting the shore power cable from the Vessel is not a regulated action and can be done by an unqualified person.